FAMILY MEDICINEA Historical Review of a Young Departm ent

by Paul C. Brucker, M.D.

The Flexn er Report, in 1910, intro­duced dramatic changes in the natureof med ica l ed ucation. C linica l instruc­tion was shifted from physician-pre­ce pto r offices to much more organized,accred ited teaching hospitals. Therewas an emphas is plac ed upon the roleof full-time clini cal facult y for trainingin b oth the clinical and basic scie nces .

ot sur prising ly, the cur riculumbecame increasingly influ enced b y thestudy of tho se d iseas es which nec essi­tat ed the hosp ita liza tion of pati ents andint ensive services. Examination of theselected, serious problems of hospitalpatients became the norm for training;and the problem s that ambulatorypatients had did not attract nea rly asmu ch atte ntion or educational effo rt.As specific organ-related knowl ed geincrea sed , the era of specializationcame into its own.

By the 1950's, fed eral funds for med­ical research an d tra ining in resea rchtechniques b ecame an accepted pri or ­ity. Vast amounts of funds weredirect ed toward the investigati on ofthose d iseases which typi cally requiredhospitalizati on . Studies direct ed towardthe prolongati on of life, rather than thepr even tion of di sea ses were ca rriedout, with tea chin g hospitals serv ing asthe clinical lab orator ies. Dramati c,

almost miracle-like advances werema de in medicine. Open hear t surgery ,organ transp lantati on and dialysis arejust a few of the techniq ues thatresulted from this co nce ntra tion ofeffo rt.

In this climate of success and seem­ingly unlimited supply of resear chfunds, there was a stea dy incr ease inthe number of able students who fol­lowed their mentors into specialtycareers. Even the genera l internist , tra­ditionally the diagnostician or the "doc­tor 's doct or ," b egan to disappear. Man yof the good stud ent s felt tha t the "rea lac tion " lay in specialty fields, not inge ne ra l medi cin e, ge nera l pedi atrics orin ge ne ra l practi ce. By 1974 there we refour specialists for every ge nera l pr act i­tion er in the nited Stat es, whi le inGrea t Britain there were thr ee primarycare physicians to one specialist. Pre­ventive medicine was not p opular , an dther e was a tenden cy not to emphasizethe psych ological needs of pa tients andthe effe cts of illness up on the socialunit. Man y persons came to feel thatthey co uld not find a well-trained per­sonal physician wh o would allow eas yentry into the medical system and wouldhelp moni tor and manage their ca re ­regard less of whether it be in the out- orin-pa tient sett ing . They expe cted an d

wa nted a ph ysician who could provid eco mpre he nsive and continuous car e.

Allopathic specialty ph ysiciansbecame co ncerne d as they found them ­selves incr easingly depend ent up onprimary ca re osteopaths as the onlyreferring primary phys icians in theirco mmunities . T hey too sensed a lack ofproperly tr ained primary care ph ysi­cians who co uld select appropriate,interesting and co mplex patients whowould require specialized d iagnosis ortherapy.

T he reports of the Willard and MillsCom mission in the mid-1960's furt hercalled atte ntion to these trtjnds.

ationa lly, the ge neral practitionersbecame co ncerne d lest they disappearfrom the scene of organized and aca­demic medi cine. They sought toimprove their sta ture and to do awaywith the pejorative, commonly usedlabel of " the local med ical doct or or theLMD ." They recogni zed tha t theywou ld have to up grade the training andqu alifi cati ons of those ent erin g practicein the 1970's. In 1964 they went to theAme rican Boa rd of Internal Medi cineand asked for approval of a new typ eof resid en cy training for primary careph ysicians or family physicians. Th eAme rican Board of Int ernal Medicinerefu sed the request that fam ily rnedi-

2 JEFFERSON ALUMNI BULLETIN SPRING 1988

, Paul C. Bruck er, M.D . became amember of the Board of FamilyPractice in April 1983. During thenext five years he served 011 theCont ent Validity Co m m ittee, theLong-Ran ge Planning Co m m it­tee, the Standard Setting Co m ­mittee, the Research and Devel ­opment Co m mittee, the Cre­dential Co m m ittee and the Ex ec­utive Co m m ittee. From April1986 through March 1987 Dr.Brucker served as Secretary­Treasurer and then fro m April1987 th rough March 1988 as Pres­ident of the American Board ofFamily Practi ce. He co ntinues tobe an acti ve m ember of th eBoard's Item Writ ers Committeeand the Edito rial Board of theJoumal of Family prdctice, andserv es as therepresentatioe of theAmerican Board of Family Prac­tice to the American Board ofMedi cal Sp ecialties.

Dr. Bruck er

cine become a subspe cialty of int ernalmedi cine. Subsequentl y, in 1969, con­cerne d family physicians w ere abl e toconvince organized acade mic medicineof the need for a thr ee year, specialtytraining program in family practice andthe American Board of Family Pra cticewas estab lished. Much of the cred it forthis achi evem ent must be giv en to

icholas J. Pisacano, M.D. , who ledman y of the discussions relat ed to theWillard and Millis rep orts, and wh obeca me the first Executive Secr etaryof the Ameri can Board of FamilyPractice.

Jefferson 's Dean, William F. Kellow ,M.D ., knew Dr. Pisacano well. He fre­qu ently talk ed with Dr. Pisacano ab outthe new specialty of family practiceand the possibility of estab lishing afamily medicine program at Jefferson.He too wa s always mindful of the med ­ical needs of the community and wa sconcerned about the disappearance ofprimary care. In 1967, Dean Kellowinvit ed Franklin C . Kelton , M.D ., andDa vid W. Kistler , M.D. , two officer­lead ers of the Pennsylvania Acad em yof Family Physicians, to join him in adiscussion of how the training of the

primar y ca re ph ysician might bes t beaccom plished . Doctors Kelton andKistler abl y expressed their belief thatfamil y practice shou ld be a distinctprogram at the Co llege.

Th e Beginning of Famil yMedicin e at ] ef ferson

In 1971, under Dean Kellow's leader­ship and with faculty approval, a Di­vision of Family Medicine was estab­lished at Jefferson in the Departmentof Community and Preventive Medi­cine. Willard A. Krehl , M.D ., then Pro­fessor and Chairma n of that depart-

JEFFERSON ALUMNI BULLETIN SPRING 1988 3

ment, wa s enthusiastically sup po rtiveof the ve nture. Doct or s Kelt on andKistler helped him to estab lish twenty­five precepto rships in famil y practi ce.In the first year, 40 students chose theelective six-week p receptorship . Ingene ra l, they were overw helming lyenthusiastic abo ut the experience!

Shortly ther eafter , in 1972, withfacu lty and Boa rd approval, formalarrangements were ma de to estab lish asepara te Department of Family Medi­cine. A sea rc h b egan for the firstcha irman of the new departmen t.

Joseph S. Gonnella, M.D ., then theAssistan t Dean in C harge of Aca demicAffairs, sub mitted my name to theSearch Com mittee. Dr. Go nnella and Ihad worked closely for so me four yearsin the develop ment of a program forthe evaluation of medical care. Thiswor k was subseq uently published andpr esen ted at sc ientific meetings. WhenI wa s initially approached to co nsiderthe ca nd idacy for the chairma nship Iwas flatt er ed , but at the same tim e tornbetween the oppor tunity for suc h aposition and the wonde rful one tha t Ihad in a 100 year old bTfOU P famil ypractice in Am bler, Pennsylvani a, asub urb of Philad elph ia. One of m y fourpartner s was Dr. Kelton, on e of thefam ily ph ysician s so instru menta l inestab lishing the fam ily medicin e pro­gra m at Jefferson.

Dean Gonnella wa s ve ry persuasive!I ag reed to accept an invitation to meetwith the Sea rc h Committee. As far as Iwas co ncerned , the date of the firstmeeting wa s kept a secre t. All o f themembers of the Committee kn ewabout the time and date, but so mehow,inad vertently, I wa s not infor med . For­tunately, Dean Kellow discovered th is,and the night bef or e the meeting ca lledto express his regr et s about the ov er­sight! We b ot h had a good lau gh , andafte r so me hast ily rea rranged plan s Iwa s able to meet with the Com mi tteethe next day.

The Sea rch Committee was impres­sive . T hey had an und erstand ing ofprimary care, w ha t the formation of anew department might entail, and thed irect ion that they wa nted the depar t­ment to tak e. It was a tribute to theca reful prepara tory wo rk that had go ne

int o the d ecision to form such adepartment. After an enjoy able meet­ing with the Committee, I returned toAm b ler, only to be called that sa meevening b y Dr. Kellow to det ermine if Iwa s willing to meet with some of theothe r chairmen in the Colleg e. Nota bleamo ng those with who m 1 met wasThomas D. Duane, M.D ., the Chairmanof the Department of Ophthalmology,and also Cha irma n of the Curricu lumCommittee. Dr. Du an e took a greatdeal of tim e in explaining the int ent ofthe newly revised curr iculum , whichincl ud ed a manda to ry six-w eek clerk­ship in family med icine. Robert L.Brent , M. D., the Professor and C ha ir­man of the Department of Pediatrics,in an unselfish manner was helpful an dencouraging . Robert T . Wise, M.D., theMagee Prof essor and Chairman of theDeparment o f Medicine, ca utiouslysuppor ted the conc ept of the newdepart men t and curricular cha ng es; buthe was co nc erned about the quality ofmedical student training that a newd epartment with new facult y migh tma ke ava ilab le. I apprec iated hisco mments and co ncern about ma ttersof q uality .

After seve ra l weeks of di scussions,the well-laid plans, the recepti veness ofthe senior fac ulty, and the encourage­ment o f Dean s Kellow and Go nnella,a ll con vinced me that the new chair­manship wou ld be a wonderful oppor­tunity. 1 was pleased that the Colleg esaw fit to offer such a position , and onJanuary 1, 1973, I became the first Pro­fessor and C ha irma n of the newdepartment in both the Medical Col­lege and Hospital.

Parentheti cally, almost simultan e­ously with m y ac cepting the posit ionthe chairman of the Haas CommunityFund, Mr. Hich ard Bennett, ca lledDean Kellow to ask why the fun dswhich the fo undation had awar d ed theMedical College in 1971 to estab lish thenew department had not yet been used .When Dean Kellow told him that "a Dr.Bruck er" had been invit ed to chair thedepar tm ent he was asto unded , fo r Ihad b een Mr. Benn ett's friend and per ­sona l ph ysician for 13 years. Fortu­na tely, this relationship has continueduntil tod ay. Mr. Benn ett wa s the first

One of the initial problems wi th theam bula tory clerkship was w here toplace 223 junior students. Sufficientlylar ge outpatient activities with exce llentsuperv ision had to be ident ified .official" fam ily practi ce pa tien t atJefferson!

Th e Beginning of theDepartment

By the tim e I arrived on campus inMarch 1973, ren ovati ons to the oldScott Library on the first floor of theCollege bu ild ing wer e nearl y complete .T he attracti ve new fac ility includ edfive offices for facult y members, anoffice for the cha irman, and adeq uat espace for clerica l help . Missing, how­eve r, wa s the furniture, which had notarrived on tim e. I began my tenurewith an old army desk and a search fora desk chair.

At our meeting that first day, DeanKellow repeat ed the previous chargethat 1 was expe cted to estab lish under ­gra d ua te, grad uate and postgraduateteach ing programs, and eve ntually,once the depar tm ent was estab lishe d ,to d evelop a resear ch program . A verypleasant memor y abo ut the develop­ment of these programs is the supportlent by Dean Kellow, Dean Gonnellaand Mr. Thomas Murray, the BusinessAd mi nistrator o f the C ollege. Theyalways had tim e to listen , to eva luateand to offer co nstruc tive advice,rega rd less o f the ma gn itude of theproblem or their bu sy sche d ules.

Th e Undergraduate FamilyMedicine Curriculum

The first manda tor y Family Med i­cine Ju nior C lerkship was sta rted in theFa ll o f 1974. T he cur ric ulum, w hichwas d esign ed for this clerkship ,em phasized the develop ment of anamb ula tory expe rience that would pro­vide ready access for patients, allowco ntinuity and co m prehensiven ess o fca re, and give att en tion to the psycho­social need s of the fam ily. Sim ultan e­ously, a cur riculum wa s designed forthe senio r yea r elective. Even in 1974the Cu rriculum Commi ttee wa s awareof the up coming em phasis that wouldbe p laced on ambulato ry ca re tra ining.j efferson's cur riculum wa s way aheadof the tim es!

4 JEFFERSON ALU ~I I BULLETIN SPRING 1988

Resident Robert Motley , M.D. , '85 checks patient Robert Smith as Clinical AssistantProfessor Richard C. W ender, M.D. and Mrs. Smith look on.

JEFFERSON ALUMNI BULLETIN SPRING 1988 5

Clinical Assistant Professor Robert L. Perkel , M .D .

Among the existing Jefferson affilia­tions was the Wilmington Medical Cen­ter. Th ere, und er the direction of DeneT . Walt ers, M.D ., was an excellentresidency program. It was a logicalchoi ce to include Wilmington MedicalCenter as one of the first affiliate sitesfor the und ergraduate clerkship. Simul ­taneously, the Chestnut Hill Hospitalexpressed a rekindled desire to estab­lish a famil y practice resid ency pro­gram and to accept und ergraduate stu­dent s for the clerk ship. Harry Kaplan,M.D . was nam ed the first dir ect or ofthis pr ogram. Up until the pr esent tim e,both of these institutions have made avaluable contribution to the und er­grad uate teachin g. Still, the Depart­ment lacked an ad equate number ofspaces.

In late 1973, a discussion wa s begunwith the Richard K. Mellon Foundationand representatives of the Latrobe AreaHospital in Latrobe, Penn sylvania,abo ut the possibility of an affiliate pro­gram in famil y medi cine. Th e Hospitalwas seeking to estab lish amedicalschoo l affiliation in order to attract aneven bett er and more diverse medi calsta ff; to improve the qualit y of patientcare , seco ndary to the stimulus that aneducational program wo uld provide;and to serve as a training site for famil yph ysicians wh o were sore ly need ed inLatrob e and the sur round ing ruralcommunities. After an extensive studyby the Mellon Foundation about theadv isability and feasibilit y of such anaffiliation and educa tional pr ogram,the Foundation gav e the Latrobe AreaHospital a grant to build a clinica l out­patient faci lity wh ere the studentscould see ambulatory patient s, and alsoto estab lish housing for both the und er­gra d uate students and anti cipated fam­ily pr actice resid ent s. This was a greatassist!

On ce the Lat robe Area Hospital Affil­iation was well und erway, the Co llegeturn ed to face a soc ietal concern for thebett er distribution of family ph ysician s.In 1974, there were severa l counties inPenn sylvania with just tw o or thr eefamil y ph ysician s. Conseq uently, thePhysician Shortage Area Pro gram(PSAP) was established . Under this pr o­gram the College would accept as

many as tw elve qualified stude nts fromeithe r urban or rural physician shor tageareas, with the und erstanding that thesestudents would pursue the und ergradu­ate famil y medicine curriculum at Jef­ferson , selec t a famil y pr actice resid ­ency program, and eventually return toa "shortage area ." This program hasbeen very successful. It wa s expande din 1978, and at the pr esent tim e itallows the Coll ege's Admissions Com­mittee to pr eferentially admit up totwent y-four students per year­providing their academi c crede ntialsar e similar to thos e of other studentapplicants. Many of the student s whohave gone through this program arenow practicing in shortage areas . Itssuccess has attracted a great deal ofregional and national attenti on .

The Residency ProgramShortly aft er arri ving at Jefferson in

1973, I submitted an application to theResid ency Review Committee for afamil y practice residency to be estab­lished at the University Hospital. Muchto my dismay, in September 1973, thisapplication was not approved. On thesame da y that the Department was no­tified of this I made telephone arrange­ment s with the educational represent a­tive, Rob ert Graham, M.D ., at theAmerican Acade my of Family Physi­cians in Kansas Cit y, Missouri for acon sultative appointment . He agreed tosee me that same night. After I arrivedin Kansas Cit y that evening , the tw o of

us stayed up until the wee hours of themorning rewriting the application. Thenext day the application was retypedand resubmitted to the ResidencyReview Committee. In Decemb er 1973provisional approval was finallygained , and the Department was abl eto begin the first fam ily practice resi­dency at Jefferson in July 1974.

Residency Review Committeeapproval was just the first hurdle toove rcome in starting the pr ogram. Thenext major one was to ob tain salariesfor eightee n residents, six for eac h ofthr ee yea rs. Weeks of meetin gs withadministrators, committees anddep artment al chairm en followed .Understanda b ly, no existing residencyprogram wished to give up residencypositions so that salaries could beob tained for the fam ily practice resi­dent s; and similarly, there was only afixed amount within the Universitybudget for training house officers . Tofurther compo und the pr ob lem , man yof the existing residency programs,with increased servic e demands,wa nted to expand their own plans.

Th e solution to the probl em cam eab out rather unexpectedly. When PeterHerbut, M.D ., the President of theUniversity, asked me to give a progressrep ort to the Board of Trustees on thesta te of the new department, I quicklyrealized that it wo uld be emba rrassingto the Presid ent to share my frustra­tions with the Board . Three daysbefore the sched uled meeting I met

6 JEPPERSON ALU MNI BULLETIN SPRING 1988

with him to ask that I be excused fromgiving the report. When Dr. Herbutdiscover ed the reason for my hesitancy,he found the necessary funds for theresidency positions with a sing le phonecall. Three days lat er I was ab le to givea glowing report to the Trustees.

The dela y in the approval of theresid en cy applica tion and in obtainingsalaries for the residents hamper ed ourinitial recruitment of residents. It wasimpossibl e to promise applica nts eithe ra salary or an appro ved progra m pri orto the end of December 1973, just sever­al we eks b efore the deadline for the

ati onal Int ern and Resident MatchingProgram. Much to our surprise, how­ever, four out of six positi ons wer efilled throu gh the Mat ch and theremaining two wer e quickl y filled afte rthe match results were announced . Afull co mp lement of six resid ents wereenrolled to begin the first family prac­tice resid ency program at Jefferson inJul y 1974! These tru stin g pioneers andthe medi cal schools which they repre­sented were: David Cheli, M.D., TheMedi cal Colleg e of Pennsylvani a; San ­dra Harmon , M.D., T emple Unive rsity;Franklin C . Kelton , [r., M.D ., JeffersonMed ical Colleg e '74; Allan Kogan,M.D ., Baylor School of Medicin e;Jam es Plumb, M.D ., Jefferson MedicalCollege '74; and Mar garet Fritz Stock­well, M.D ., The University of

ebraska .

FacilitiesIniti ally, the Department lack ed tw o

requisites for both the under graduateand the gradua te pr ograms: clinicalspace and an ad equate patient popula­tion . Fortunat ely, funds to develop theovera ll program were available fromthe Haas Community Fund and theDep artment of Health, Education andWelfare. The go vernment funds wer eto be used for funding preceptorshipac tivities and there was a st ipulationthat they had to be used by Jul y 1,1973. The real priority, however , wasto establish an outpatient family prac­tice center. Therefor e, in early June1973, I petition ed the govern ment toallow these funds to be used to assistwith construction. They agr eed , butstipulated that th ey had to b e desig­nated for sp ecific constru ction prior to

Dr. McGehee

July 1, 1973. The "sq ueeze" was on.Working with the University's archi­

tect , we designed a new Family Pra c­tice Center for the Edison Building atNinth and Sansom Streets. The blue­prints were hand-deliver ed to Washing ­ton , D.C. , and were appro ved justthree days before the grant expired .Despit e our haste, this design proved tobe very practical and fun ctional. TheDepartment occupied this Center until1978, when we mo ved to the fourthfloor of the new University Hospital.

Facuity RecruitmentConcomitantly, with the establish­

ment of the curriculum , the approval ofthe residen cy program, and the build­ing of a clinical facility , a search wa sbegun for qualified faculty. I had therare opportunity to recruit a brand newfull-time faculty, but at the same tim erecogni zed that my choices would b escrutinize d carefully by the othe rmembers of the facult y. I was awar e ofthe fact that it wo uld be difficult torecruit ab le faculty to teach primaryca re , for there was not an ab undance ofsuch individuals and the demand, withall the new training programs in pri ­mary care, was high.

Edward H . McG ehee, M.D ., '45, afriend and colleague of mine, was thefirst potential cand idate to be co n­tact ed. Trained as an internist, wi thadd itiona l trainin g in hematology andpathology, Dr. McGehee was a muchloved and respected "family physician"practicing genera l int ern al medi cin e inthe C hestnut Hill section of Philad el­phia. He was well kn own for makinghouse calls on his bicycle, working ve rylong hours, and alwa ys being ava ilableto the stud ents who cro wded his pri ­va te office. Dr. McGehee had cha iredthe Department of Med icin e at Chest­nut Hill Hospital , and had serve d asPhysician to and Hem atologist to thePennsylvani a Hosp ital and the Ben ­jamin Frankli n C linic.

Dr. McG ehee was ver y settled andsat isfied in his established pract ice.Initially, he and his wife, Carolyn, weredubious about the po tenti al of joiningthe Jefferson facult y. However, aftermany meetin gs, and wi th som e recru it­ing help from Drs. Gon nella and Kel­low , Dr. McGeh ee became "so ld" onthe entire idea of training famil y physi­cians, and in 1974 he returned to hisalm a mater as Pro fessor of Fa milyMedicin e.

JEFFERSON ALUMNI BULLETIN SPRI NG 1988 7

Clinical Assistant Prof essor Christo pher Chambers , AJ .lJ., with th e Mur rellfamily

Dr. McGehee's co ming to Jeffersongave me the idea of approaching an otherco lleague and friend to b oth of us, Wil­liam . Meb an e, III , M.D. DoctorMeban e practi ced pediatrics in Chest­nut Hill for many years and he too wasac tive on the staff of th e Chestnut HillHospital. In 1974 he was coaxed awayfro m his very successful private gro uppract ice to b ecom e a Clinical Professorof Family Medi cin e. He remained onthe Jefferson ca mp us for two yea rs;and in 1976 he moved to the a ff iliatedfamily medi cin e program at ChestnutHill Hospital, wh er e he served as anAssociat e Director of the training pro­gram until 1985, when he b ecame itsDirector.

The Ches tnut Hill community didnot tak e lightl y to the loss of two of itsmost resp ected ph ysicians to the newdep artment at Jefferson . I receivedman y co ncerned phon e calls about thesitua tion. Fortunately, most of theChes tnut Hill resid ents were under ­stand ing about the need for go od rol emodels in training future physicians.The number and intensity of the callstestifi ed to the quality of the twofacult y members that had agreed toco me to Jefferson . In ac tua lity , manyof the ca llers followed b oth ph ysiciansto Jefferson as their patients. Theloyalt y of these initi al patients and theirenrollment in the Jefferson practicewere extre mely valuable in training thefirst students and residents.

OutpatientsThe full-time faculty's privat e patient

population was not in itself suffic ient,however , to conduc t an ambulator ycare progra m. A mu ch larger numberof patients was required. In 1974 therewas a fortuitous change in the Hospi­tal' s policy and organizational struc­ture: the traditional outpatient clinicsys tem which had b een in place wasdisbanded in favor of a more tradi­tional "privat e" sys tem. With a largernumber of adult, medical clini cpatients to be pro vided for , the Hospi ­tal felt fortunate in havin g a newdepartment so interested in ambulatorycare and in need of such patients forteaching. Dean Kellow and the Vice­Presid ent for Health Services, Frank J .Sw een ey, Jr. , M.D. , '51 felt that it

would be highl y appropriate for theFamily Medicin e department to tak eover the care of these patient s. In 1974the transfer was made.

At first , the clinic patients were skep ­tical that their needs could b e tak encare of in a single large, clinical facility.They wer e used to b eing referred to anumber of subspecialty clini cs, primar­ily focused on the traditional medicaland surgica l spcialties . Usua lly, ther ewa s no appointment syste m and it wasfirst co me, first served; a process thatnec essitated lon g hours of waiting. Itwas rare that the patients would see thesame physician over a prolongedperiod of tim e.

When famil y medicine becameresponsibl e for this patient population ,ev ery effo rt was made to assign aprimary physician for eac h patient.Appointments wer e made, and in manyinstances, the necessity for multiplesubs pecialty typ e visits to oth er physi­cians or faciliti es was elim inated . This

was a tremendous change for a largenumber of individuals. At first theywere shocked and dubious. T he initialappointment co mpliance ra te was 20per cent. As tim e went on and pro fes­sional relationships developed with theFamily Medicin e sta ff , the appoint­ment co mpliance improved . Two yea rslat er , approximately 60 percent of thepati ents kept their appointm ents.

Initially, about 60 percent of the fam­ily medi cine patient population camefrom the disbanded clinic system. Thispatient population wa s not abl e toafford the traditional professional feesand this meant that the Institut ion hadto subs id ize the clin ical operation . Thissubs idy, necessary for the program andappreciat ed , was negotiated on anannual basis. This was always a tryingtim e for me and the Hospi tal's ad minis­tration . Primary ca re training is themos t expensive kind of training, for itrequires a great deal of continuoussupervision and the rewards for service

8 JEFFERSON ALUMNI BULLETIN SPRING 1988

Dr . Bru cker and resident William Th ompson , M .D ., '87 revi ew th e progress of (III in-patient ,

are considerably less than they are inthe procedural typ e specialties.

InpatientsTh e responsibility for the manage­

ment of the inpatients generated fromthe Department's outpatient populationaroused a great deal of discussion.From the very beginning the Chairmanof the Department of Int ernal Medi ­cine, Rob ert I. Wise, M.D. , wasgenuinely concern ed that family physi­cians might not poss ess the necessaryknowledge and skill to car e for adultpati ents in a hospital setting. He hadnum erous anecdotes to support hisconcern. Many members of theDepartment of Medicine felt that fam ­ily practice in the United States shouldbe similar to general practice in GreatBritain , where inpatients were custom­arily referred to the hospital-based spe ­cialists. Members of the Family Medi­cine department, on the oth er hand,vigorously disagreed with such a con ­cept and felt capable of handlinggeneral medicine typ e patient s in the

hospital setting. In addition, the accred ­iting organizations for family practicetraining insisted that the famil y ph ysi­cians must have such responsibility. Infact , the y encouraged family ph ysiciansto ask for obstetrical and surgical privi­leges , something which I did not andstill do not think is appropriate for fam­ily physicians to request in a geogra­phic setting such as Philadelphia.

Man y meetings ensued to resolve thisdilemma. Dean Kellow and Dr. Swee­ney convened the leaders of eachdepartment in an effort to find a satis­factory solution. Finally, Warren D.Lambright, M.D ., an associate of Dr.Sweeney in the Hospital's administra­tive offices, effe cted a solution: Allinpatient s would be admitted to theHospital on the medical service. Allqualified faculty in the Department ofFamily Medicine would receive secon­dary appointments in the Departmentof Int ernal medicine. The Chairman ofthe Department of Family medicinewould be responsible for the qualityof the family medicine patients ' care

and the professional conduct of hisfaculty. Should there be some fla-grant discrepancy, the Chairman ofthe Department of Medi cine wou ldhave the right to intervene if the caredid not meet the usual standards.Dr. Wise felt comfor table with thisarrangem ent , and incid ent ally, not onc efelt obligated to co me to me to com­plain about inpatient ca re issues. Asimilar arrangem ent was established be­tw een Dr. Wise and myself for outpa­tient care. A see mingly insurmoun tab lehurdle was passed . Ten years later, in1984, Willis C. Maddrey, M.D., thesubsequent Chairman of the Depart­ment of Medicine, suggested tha t theDepartment of Family Medi cine haveits own inpatient service, since it hadlong since demonstrated its ability tocar e ad equately for such patient s.

Thus, in tw o years, the new Depart ­ment had a sound faculty, und ergradu­ate and graduate programs, aff iliateprograms, an outpatient facility with anad equate patient population, and theprivilege to admit and care for general

JEFFERSON ALUMNI BULLETIN SPRING 1988 9

Associat e Professor Howard K. Rabinowitz , M.D . w ith pat ient A d rianna Yanezand her fath er .

adult medical patients in the hospital.Without the Institution's real commit­ment to the program, not nearly asmuch could hav e been accomplished insuch a short period of tim e.

Maturation of the DepartmentUnde rgrad uate Programs

On ce estab lished, the new depart­ment grew quickly. By 1976, four addi­tional full-time faculty had been re­cru ited : Peter Amadio, Jr. , M.D ., '58;Su Hain , M.D .; Howard K. Rabinowitz,M.D. ; and Elmer J. Taylor, M.D .. '52.Th eir specialty representation, whi chespe cially suited a primary care train­ing pr ogram, was in a proportion thathas recently received favorablenational attention. These ph ysicianswere trained in internal medicine, fam ­ily medicine and pediatrics.

In addition to the family medicinefacult y, the department has alwa ysenjoyed the coo pera tion of facultymembers from the oth er department sin the Coll ege. Throughout the fift eenyears that I have been at Jefferson , nofacult y person has ever refu sed tocoopera te; and in fact many havevoluntee red to teach in the program.Thi s spirit of coope ration has led to ahealthy integration of Family Medicineinto the University setting.

With the increase in the number offacult y came an increase in the amountof undergraduate teaching responsibil ­ity. The department became involvedin the freshman clinical correlationcourses, and the Medicine and Soci etyCourse in the sophomore year, teachingepide miology and exploring medicole­gal and ethical aspects of health-caredelivery issues.

Becau se of the dem and from theseniors electing the famil y medicinetra ck , the rural pr eceptorship programhad to be expa nde d . With the help offed eral funding, ca re fully selec ted fam ­ily ph ysician pr eceptors in rural offi cesfrom Vermont to orth Carolina werechose n to serve as pr eceptors. HowardK. Rabinowit z, M.D . has been resp on­sible for the supe rv ision and organiza­tion of this pr ogram. It allows the stu­dent s to see unselected problem s invarious typ es of communities, to liveand particip ate in the community, and

to have one on one teaching. The stu­dents ar e always amazed at the diver­sity of problem s which they see, andthey become increasingly impressedwith the role that psychosocial factorsplay in keeping individuals well andrestoring them to health. The precep­tors have developed a real esprit decorps! Every year they return to Jeffer­son for a thr ee day workshop to up­grade their medical knowledge, tointroduce them to the potential seniorpreceptees and to discuss ways inwhich the program can be improved .

The Department also added twomore affiliate programs to the thr eethat were already in op eration. TheBryn Mawr Hospital program, underthe supe rv ision of D. Stratton Wood­ruff, M.D. , was added in 1975, and theUnderwood Memorial program inWoodbury, NJ was added in 1983.

Residency Programs

The first residents to enter the pro­gram in 1974 performed admirably.They proved to be good ambassadorsfor the Department. It was not longbefore the resid ency program devel­op ed a creditable reputation bothinsid e and outside of the institution.Residency applicants were quick torecognize the potential ad vantage ofbeing abl e to train for family medicinein a medi cal school setting. The initial

hurdle of attempting to fill the resi­dency class was soon ove rcome, andaft er the first yea r of the program therehas been a large pool of qualifiedapplicants from Jefferson, and frommedi cal schoo ls all over the country.All of the graduates of the residencyprogram have passed the certifyin gexamination of the Ame rican Board ofFamily Practice. They are engaged inpractices that ran ge from hamlets tometropolitan cities in the Unit ed States.Several have gone outside of the coun­try to pract ice. Ten of the past gradu­ates and seven of the 18 current resi­dent s are Jefferson alumni.

In 1978, the residency programreceived full accred itation . On e con ­stant concern of this acc rediting bod yis the belief that famil y physicianstrained in the Northeas t should beequippe d to do obste trics and surgery .After many discussions with the Resi­dency Review Committee we reacheda compromise. All of our residentsreceive a certain amount of obstetri caltraining as specified in the ResidencyEssenti als for Famil y Practice and allof the resid ent s expe rience a twomonth surg ical rot ation with emphasison dia gnosis, pr e- and post-op care.For those who plan to practice obstet­rics, a six month obstetrica l fellowshipis available at the comp letion of thethr ee year resid ency.

10 JEFFERSON ALUMNI BULLETI N SPRING 1988

The presence of the Family Medicinepr ogram at Jefferson , togeth er with anati onal trend toward interest in prim­ary car e, has result ed in a significantincrease in the number of Jeffersongradua tes go ing into famil y medicineresidencies. In 1973, approximatelythree grad uates per year elected tospecialize in famil y medicine. At thepresent tim e approximately 16~ of theJefferson graduating class es ente r thefield -a number somewhat above thenati onal average.

Four grad ua tes of our program ar ecurre ntly full-time facult y members inthe Department. They ar e: ChristopherV. Chambers, M.D ., Rob ert L. Perk el,M.D ., Michael P. Rosenthal, M.D. andRichard C. Wender , M.D . In addition,four of our graduates serve as faculty inresidency programs elsewhere. TheDep artment has attempted to create aresidency program whi ch is op timallydesigned for all resid ents , regardless oftheir eve ntual practice typ e or location.

Postgraduat e Programs

All diplomates in famil y practice arerequired to tak e at least 150 hours ofapproved co ntinuing medical ed uca­tion co urses eve ry thr ee years in orderto qualify for the mandatory recertifi­cation examination that is given everyseven yea rs. This requirement makes itfitti ng for the Department to co nd uc tannual continuing ed uca tion co urses .Som e of these hav e been cond uc ted atJeffe rson, while many have been heldelsew he re, frequently in co njunc tionwith some other spo nso ring bod y suchas the Unive rsity of Delawar e, theAlumn i Assoc iation or a me dica lsoc iety.

Research Programs

Other than clinical trials co nd uc tedby various members of the faculty,there was no concerted research foc usin the department until 1982, whenDonald J. Balaban, M.D. , M.P .H.joined the d epartment as Resear chAssociate Professor of Family Medi­cine, and becam e the director of theGreenfield Research Center. Beforecoming to Jefferson Dr. Balaban wa saffiliated with the Leonard Davis Insti­tut e at the Unive rsity of Pennsylvania,wh ere he wa s involved in health care

Left to right : Elmer]. Taylor , [r ., M.D. , '52, Pet er Amadio, [r ., 1'.1.0. , '58 andEdward H. McGehee, M.D .,·'45.

Left to right : Health Services Research Fellow Sandy Peinado , M .D . withResearch Associate Prof essor Donald J. Balaban, iH.D.

JEFFERSON AL ~I NI BULLETIN SPRING 19 8 11

delivery resear ch , especially the stud yof fun ctional outco mes in chronic con­ditions. He brought with him an enthu­siasm and expertise to conduct similarresearch at Jefferson , and was anxiousto be involved in the faculty's scholarlyefforts. In ad dition to this role, alongwith Richard L. Brown, M.D. he hasbeen resp onsibl e for the Department'sFacult y Fe llowship program. The well­tra ined junior faculty and the ResearchCe nte r's presence lent an importantaca demic stim ulus to the Department.Resear ch questions began to be raised,and me tho do logies were developed forpursuin g the answers.

Economic Influenc esIn 1982, the advent of the Prosp ec­

tive Payment System (PPS) for hospital­ization brought changes in the fundingand delivery of care. It was nowappa re nt that society was going toimpose limits up on the cos ts of inpa­tient ca re. For the first tim e in Am eri­can medicin e, there wer e debates abo utthe ra tioning of care and,the effe ctive ­ness and effic iency of ce rtain types ofcare . T he pri vate, co rpora te sec to rbegan to exert a stro ng influ ence up onthe organiza tiona l structure of healthcare delivery, including the pa ym entmechanism . Almost overn ight, medi­cine ca me to assume mu ch mor e of abusiness posture. While different typ esof capita tion systems sprung up for thewe ll and employed , gove rn me nt subsi­dies for the care of the poor and theelde rly becam e limited. It wa s appar­ent that hospitalizati on , the mostexpensive part of health care, would becu rta iled . The PPS was particularlythr eatenin g to mos t of the nati on 'steaching institutions, for the majority ofthem are located in urban poor ar easwhere m uch of the care has to besubsid ized .

For the first tim e in 60 years, theoutpatien t se tting and the concep t ofambulatory care began to tak e on anew significa nce, while at the sam etime me dica l schools were turning outa surplus of ph ysicians. Terms such as"compe tition" and "doctor-glut" we recommon language, and residents andstude nts began to be concerne d abo utfinding a job after finishin g residencytraining.

Dr. Perk el makesa house call.

Jefferson was attuned to thesetrends, and in its long-range planningattempted to ensure that the institutionwould remain fiscall y sound, while stillfulfilling its mission of educa tion,patient ca re and research . TheDepartment, in coo pe rationwith thehospital administration , particip ated invari ous typ es of ca pitation paymentprograms. Some of these weredesigned primarily for the wo rking­well, but other such as HealthPass we recreated for the poor and the elde rly . In1986, sat ellit e fam ily practice ce nterswere estab lished in the Fairmount sec­tion of Philadelphia, and in South Phil­ad elphia; and in 1988 a third sate lliteoffice wa s started in China town. Th epurpose of the satellite offices was tobe involved in the community, provid eneeded primary ca re, and serve as asource of pa tients for the educa tiona lprograms.

In order to staff these sate llites , theDep artment again invited severa l of itsgrad ua tes to participate. David J. An­derson , M.D ., completed his residencyin 1987, is the staff ph ysician for "Jeff­care," an HMO type program that is a

subs idy of Blue Cross. John W. Strin g­field , M.D. and Ju dith Shimer String­fie ld , M.D. met and trained togeth er inour residency progra m. Aft er gradua­tion in 1983 they entered private prac­tice in North Carolina, but returned toopen the first Jefferson sponsored satel­lite in the Fairmount sec tion of Phila ­delphia in August 1986. David E. Nick­lin, M.D ., who gra d uated in 1984, andNe il S. Sko lnik, M.D. , who graduatedin 1987, staff the South Philadelphiafamily medi cine practice on a part -tim eba sis. Dr. Nicklin also has a pri vatepr acti ce in West Philadelphia, and Dr.Skolnik p ursues his writing interestsand traini ng when no t practicing at thesatellite. C lem ent C. Au, M.D ., wh owas gra d ua ted from our program in1985, returned to his nat ive Hong Kongbef ore rejoin ing the department toopen the new practice in Chinatown,just north of the well-known China­town "arch."

It is still too early to evaluatethe impact of these cent ers . Th etraining of students and residents in aca pitation model requires skill, forintelligen t use of resources and logical

12 JEFFERSON ALUMNI BULLETIN SPRING 1988

Instru ctor Clem ent Au, M.D . w ith recep ­tion ist Th anh Tra n in the ne west sate llitece nte r.

Geriatrics Program N urse Coord inato r Su zanne Sherry withDr. Perkel. Below right: In stru ctors f ohn W. Stringf ield , Af. D .

and l udith String f ield , M .D . at the Fairm ount ce nte r.

Dr . Au and Patient .

Merle Happe, receptioni st in th e bu syPat ien t O ff ice, with Dr. Amadio.

JEFFERSON ALUMNI BULLETIN SPRING 1988 13

decision analyses are required in orderfor the practice to remain finan ciall ysound . This parti cular typ e of expe rtisewill be even mo re important as theresidency grad uates becom e dep endentupon these mod els for employ ment.The Dep artment is continuing to doresearch on these programs so thatthere will be a factual and statisticalbasis for the managem ent decisionswhi ch will be required.

1984, wh en he becam e the first EllenM. and Dale S. Garber Professor ofFamily Medi cine. We all we re proudthat Dr. Garber left such a herit age tohis College and to the new dep ar tm en tof which he had becom e ve ry fond.

In 1982, Mrs. ellie T . Haac, whohad been a pati ent in Jefferson Hospi­tal rep eat edl y over a span of 50 yea rs,left a generous sum to be used fordepartmental programs.

As the Department's pro grams ex­panded , the offi ce space on the firstfloor of the Coll ege building was nolong adequate. The Pew MemorialTrust came to the rescue with a verygen erous grant for renovations to bemade on the fourth floor of the Curtisbuilding. The Department moved tothese new offices in 1983.

In an increasin gly restri ctive financialclimate, the Research Division had dif­ficult y funding vari ous research pr o-

jects and stipe nds for fellows. Mr. Gus­tave Amsterdam, a member ofJefferson's Board of Trustees and theBoard of the Etelka J. Greenfi eldFo undation, became aware of this and,ac ting as an intermediary, coordinateda generous gift from the Foundat ion tothe Research Division. In recognit ion ofthis gift , the Research Division wasrenamed the Etelka J. GreenfieldResearch Center of the Department ofFamily Med icine in 1985.

All of the ind ivid ual gifts, plus thededi cated efforts of man y indi vidualsin an institut ion that has been mostsuppor tive of a new dep art ment, haveallow ed much to be accomplished in ashor t tim e. A solid foundation has beenestablished and hopefully, in years tocome a recapitulation will demonstrat ethat a great deal has been accomp­lished to fur ther Jefferson's and Famil yMedi cin e's mission.D

BenefactorsTh ere have been a number of indi ­

viduals who have contributed mostgenerously to the Department duringthe 13 years of its existence, and thishistory wo uld be incomplete withoutmention of their special contributions.

Th e Alumni Association of JeffersonMedical College in 1973 voted to makean annual contribution of $50,000 tohelp sponsor the Alumni Professorshipin Medicine. Thi s honor , along with allhon orary lifetime membership in theAlumni Association, are distinctions ofwhich I am most proud.

On e very loyal alumnus was Dal e W.Garber , M.D ., '24, a respected generalpractiti oner in Delaware County, Penn ­sylvania. I had the good fortune tomeet Dr . Garber in 1976 on an alumnispo nsored continuing medical educa­tion trip to the lowlands of Europe. Hebecame very interested in the Depart­ment and, after several years of findingout more ab out the Department andhow it functioned , decided to establishan endo we d professorship in FamilyMedicine. The chair was awarded toEdward H. McGeh ee, M.D ., '45 in

Left to right: Instructor Neil S. Skolnik, u»; Residents William Thompson, MD., '87and Janice Nevin, M.D ., '87, and Assistant Professor Richard C. Wen der, M.D.

14 JEFFERSON ALUMNI BULLETIN SPRING 1988